A Worthy Diversion

One night last winter, Sally Judson was arrested for prostitution and disorderly conduct. She was also charged with resisting arrest and possession of drugs and drug paraphernalia. Judson, who has schizophrenia as well as a heroin addiction, is one of hundreds of thousands of Americans clogging the criminal-justice system for drug offenses. Many, like Judson, are also mentally ill, and the system often fails to treat the mental illness and instead ends up just submerging it in the criminal behavior.

But Judson (not her real name) was fortunate to be arrested in Pittsburgh, one of several U.S. cities pioneering a new and promising approach to treating mentally ill offenders that uses a diversion strategy supervised by newly created mental-health courts. After being arrested and placed in the intake area of the jail, Judson was identified as mentally ill by staff of the Allegheny County Office of Behavioral Health, according to the office's Amy Kroll. Two hours later, Judson went for her initial arraignment. "We drew up a service plan, and she was willing to work with us," Kroll says.

Instead of sending her to jail, the judge remanded Judson to a local crisis center followed by 28 days of drug rehab. She responded well to the treatment and afterward was placed in a halfway house. Her case was removed into a mental-health court, and in lieu of being incarcerated she was put on a structured, three-year probation. The Office of Vocational Rehabilitation helped find her a waitressing job at a local Bob Evans restaurant. On the one occasion Judson relapsed, she was speedily hospitalized.

Once a week, Judson attends a therapy group in which she and other low-level offenders learn techniques to help them avoid patterns of criminal behavior. Her urine is regularly tested for drugs. She sees a therapist who specializes in "co-occurring" disorders such as drug addiction and mental illness. If she abides by the rules, Judson will graduate from mental-health court in the fall of 2009.

"It's very intense supervision," Kroll explains. "Intense treatment. They come back for progress reports. The judge knows everything about them." Absent the interventions, Kroll believes, Judson "would have continued to prostitute. Maybe she'd have ended up dead."

***

Pennsylvania has one of America's largest and fastest-growing prison populations. More than 47,000 people are in the state's prisons, up from about 8,500 in 1980. In the past, the state has failed to develop effective sanctions to channel nonviolent offenders away from prison, and about 20 percent of Pennsylvania's inmates are serving time for drug crimes.

But since April 2007, a Criminal Justice Mental Health Task Force has been pursuing statewide reform recommendations. Five Pennsylvania counties now have mental-health courts, with Pittsburgh's Allegheny County in the lead. These courts supervise mentally ill offenders deemed harmless to the community. In exchange for agreeing to go into treatment, the individual avoids prison as long as he or she sticks to the program. A similar philosophy was pioneered by drug courts in New York, California, and Massachusetts, among other places, which have channeled tens of thousands of people into treatment programs over the past decade, helping them avoid prison.

In Pennsylvania, as in other states that have invested in better ways of interacting with the mentally ill, diversion of mentally ill offenders begins with local law enforcement. Police are specially trained in crisis-intervention methods. Lt. Francis Healy, special adviser to the Philadelphia police commissioner, describes it as "a lot of commonsense talking to people, getting police officers to know what mental illness is?teaching them how important it is to de-escalate." Dispatchers are taught that how they describe a scene determines whether police show up thinking they are going to have to tackle a dangerous felon or instead talk down a disturbed, perhaps psychotic person. Police are taught to empathize with the mentally ill, even having the symptoms of schizophrenia replicated during training sessions in which they wear earphones that bombard them with random voices. The new methods continue through to the courts and to re-entry planning, which includes how to find housing, jobs, and ongoing treatment and medication on the outside.

The strategy includes a Sequential Intercept Model. This model assumes there are five main "intercept" points, further divided into subgroups, at which a mentally ill person interacts with authorities. At each point, the person can be channeled either into treatment or into the criminal-justice system.

Intercept One is made up of first responders, primarily police officers and sheriffs' deputies; Two is the pre-booking process; Three is the court system, in particular the new mental-health courts; Four is support when a person first returns to the community from county jail or prison; and Five involves working with mentally ill ex-prisoners for the several years following their release.

Police are taught what crisis intervention training coordinator Detective Karen McLellan calls "tricks and tips for de-escalation" for dealing with the mentally ill, and the Central Recovery Center, a new 24/7 crisis center, is a place where the police can bring mentally ill offenders -- with a minimum of paperwork to fill out -- rather than arrest them. "They get a psych evaluation, something to eat, a bed; they get hooked into medical benefits and can stay there up to 72 hours," McLellan explains. "The officers are using it 12 to 15 times a month."

Cumulatively, counties that adopt this model are committing to a holistic approach to mental illness. To achieve sustained results, the model has to draw in, and draw from, an array of community resources. According to Joel Copperman, executive director of the Manhattan-based Center for Alternative Sentencing and Employment Services (CASES), which provides services to mentally ill offenders, "The mental-health court is probably not going to capture everybody coming through the system who needs those kinds of services. Mental-health courts are reluctant to take on people where there's a perception of risk. And I'm careful to say 'perception.' A mental-health court may be much more cautious than necessary. They may select people who in the public eye are the safest cases. Mental-health courts have to be done well and be willing to take risks." However, Copperman agrees that "they can be a very valuable addition to the continuum of services."

***

Five years ago, I researched and co-wrote a report for Human Rights Watch titled, Ill-Equipped. The report documented the staggering involvement, in the decades following the deinstitutionalization of the 1970s, of the mentally ill in America's criminal-justice system. We estimated that between 15 percent and 20 percent of state and federal prisoners were seriously mentally ill. More recently, the Bureau of Justice Statistics has found even higher numbers.

Whatever the exact level of mental illness behind bars, it involves the incarceration of many hundreds of thousands of people who, left untreated in the community, commit crimes and ultimately get entangled in the criminal-justice system. After state mental-health hospitals were closed, "the money didn't follow the people," Joni Schwager, executive director of the Pennsylvania-based Staunton Farm mental-health foundation, explains of deinstitutionalization. "Our county jails and state prisons have become the new mental institutions."

Often, these men and women act out in prison and are sent into high-security units to serve their sentences in 23-hour-a-day lockdown. Generally, the Human Rights Watch report found, prison mental-health systems were understaffed, medications were distributed haphazardly, record-keeping was shoddy, and symptoms of mental dysfunction were frequently dismissed as "malingering" and punished accordingly. Taser guns were often used on the mentally ill; four- and five-point restraints (arms, legs, head) were employed cavalierly, occasionally with fatal consequences, and mentally ill inmates were particularly vulnerable to being attacked by other prisoners.

Nobody is happy with this state of affairs, another byproduct of America's three-decades-long experiment with mass incarceration. Mental-health advocates bemoan the conditions faced by the mentally ill behind bars and question the ability to deliver quality treatment in a security-focused environment. Criminal-justice experts and prison administrators say prisons overloaded with mentally ill men and women are that much harder to control and that much more chaotic to manage, making the environment more dangerous for staff and inmates alike. "I don't know how some of these women were sentenced to prison," Gloria Henry, warden of California's Valley State Prison for Women, told me during my research for Ill-Equipped. "They have no understanding of why they are in prison. I don't know what purpose it serves. This is a prison, not a state hospital." And legislators express shock at the cost of running huge jail and prison systems mandated by the courts to provide expensive mental-health services to a growing percentage of the inmates. In California, the legislative analyst's office estimates that building in-prison mental-health units will cost $1.1 million per inmate so housed.

***

While states have been extremely reluctant to implement across-the-board policies designed to slow prison population growth, over the past few years several states and localities have taken steps to stop so many mentally ill people getting involved in the criminal-justice system in the first place. Many of these local initiatives have grown out of the Council for State Government's Consensus Project, in which CSG brought together experts from throughout the law-enforcement, mental-health, and prison-reform communities with the aim of forging new methods for dealing with mentally ill men and women caught within the criminal-justice system. As the project's name suggests, a new consensus is emerging that prison should be viewed as a last resort for dealing with the mentally ill -- reserved only for violent offenders -- and that money invested in alternatives to incarceration for the rest would, over the decades, reap large savings in prison expenditures.

Ohio, for example, has created a statewide coordinating center to provide tactical help to communities working to divert the mentally ill from prison. In Florida, an organization named Partners in Crisis, chaired by Broward County Circuit Judge Mark Speiser, works to create a bipartisan consensus around the need for more community mental-health resources. Similar groups have set up operations in South Carolina, Louisiana, and Washington state. Thriving mental-health courts exist in urban areas -- New York's Borough of the Bronx and Seattle -- and in rural counties such as Idaho Falls, Idaho, and Daugherty County, Georgia. In Santa Clara, California, Judge Stephen Manley has created a mental-health court specifically devoted to mentally ill people charged with serious felonies. "He's really become a national figure, pushing for more resources," says Ron Honberg, director of policy and legal affairs at the National Alliance on Mental Illness (NAMI).

While there is an emerging bipartisan consensus on the wisdom, humanity, and cost-effectiveness of the diversion model, fiscal pressures could destroy it. Many local programs have begun thanks to federal grants under the 2004 Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA), and utilizing the expertise of specialists sent out into the field by the National Institute of Corrections (NIC). However, the federal budget submitted to Congress by the Bush administration this past February proposes a complete defunding of both MIOTCRA and the NIC -- as well as of federal contributions to local drug courts and residential substance-abuse treatment programs. While Democratic control of Congress makes this total defunding unlikely, deep funding cuts could reverse many of the advances made over the past half-decade.

Of all the local approaches, Allegheny County, Pennsylvania, is widely admired as the national model. "You've got all the key stakeholders involved," NAMI's Honberg points out. "You've got buy-ins from the state as well as the local department of health. That's where the Consensus Project has really been helpful -- in fostering these kinds of collaborations and getting powerful legislators involved. Allegheny is an area that has some resources. Pittsburgh is revitalized with high-tech industry. It's a sophisticated area; [it] has a good mental-health system."

Susan Ridgely, a RAND researcher who studied the Allegheny mental-health court system in 2007, agrees. Analyzing the post-court trajectories of the 400 men and women who had been through the court since 2001, Ridgely found that long-term recidivism rates were considerably lower than they would have been absent the mental-health court's existence. The short-term costs were higher -- the courts were mandating clients into treatment centers -- but long-term costs declined thanks to the lower incarceration rates. While the statewide recidivism rate hovers at around 55 percent, courts coordinator Karen Blackburn estimates that for graduates of the Allegheny County mental-health court, the rate is as low as 10 percent.

"There's often an assumption we shouldn't be spending this money," Ridgely says. "My view is we are spending the money -- these people are already in the criminal justice system. It's a matter of how we spend the money."

A three-year University of Pittsburgh study of inmates who were provided with job training, education, drug and alcohol treatment, anger-management counseling, and other such services inside the Allegheny County Jail and after their release reached similar conclusions to the RAND study. One year after release, this group of inmates had a recidivism rate 50 percent lower than comparable individuals who had not been provided with services. The university researchers concluded that the programs, run by a collaborative made up of jail officials, Department of Human Services staffers, and representatives of the county health department, were saving the county $5.3 million per year.

"We have a program at every intercept, and they're all running at the same time," says Kroll of Allegheny County's Behavioral Health Office. "It's unique in that a lot of the counties don't have all five intercepts. We have all of them. At the very beginning, we had diversion and re-entry. Then we got a mental-health court. Then we thought, ?if we have three of the five, let's go for broke and get all five.' So we applied for grants. It's a very flowing system; there's a lot of continuity of care. There's a constant thread, so the person doesn't need to repeat his story over and over again."

At any moment in time, about 730 mentally ill individuals are involved in one or another of the institutions associated with the five intercept points. "We are not sending as many people with mental disabilities into state prison as we used to," Kroll asserts. In the recent past, Allegheny County saw about 150 mentally ill residents return from prison each year. These days that number has declined to 90.

In the 1970s, New York sociologist Robert Martinson's famous question, "What Works?" and his ominous answer, "nothing," helped discredit rehabilitation services and usher in the tough-on-crime era. A generation later, the data coming out of Allegheny County is once again making rehabilitation efforts respectable.